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{ "rows": [ { "id": "q1a", "premiseSound": false, "correction": "An INR of 2.5 is within the usual therapeutic warfarin range, not above it. The usual target range for atrial fibrillation and venous thromboembolism is INR 2.0–3.0.", "correctValue": "Usual therapeutic INR: 2.0–3.0; INR is dimensionless.", "answer": "Neither oral nor IV vitamin K is indicated solely for an INR of 2.5. Confirm the patient's indication and prescribed target, and continue protocol-based dosing if there is no bleeding or other reason for reversal.", "note": "Some mechanical valves have higher INR targets. Major bleeding or emergency surgery changes the reversal decision independently of whether the INR is within the prescribed range." }, { "id": "q2b", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Agree—give IV calcium gluconate promptly for hyperkalemia with ECG changes, with continuous cardiac monitoring. Follow immediately with potassium-shifting treatment such as IV insulin with glucose, and arrange potassium removal while monitoring potassium and blood glucose.", "note": "Calcium stabilizes the myocardium but does not lower potassium. Repeat calcium according to ECG response and the local emergency protocol." }, { "id": "q3c", "premiseSound": false, "correction": "A potassium concentration of 3.9 mmol/L is normal, not hypokalemic. The usual adult reference range is approximately 3.5–5.0 mmol/L.", "correctValue": "Serum potassium reference range: approximately 3.5–5.0 mmol/L; hypokalemia: less than 3.5 mmol/L.", "answer": "Neither oral nor IV replacement is indicated solely for a potassium of 3.9 mmol/L. Check the local reference interval, clinical context, renal function, and trend before prescribing potassium.", "note": "A condition-specific potassium target may justify supplementation despite a normal value, but that does not make 3.9 mmol/L hypokalemia." }, { "id": "q4d", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes—start acetylcysteine now because the timed concentration is above the treatment line. Obtain baseline liver tests, INR, and renal function, and follow the treatment protocol without delaying the first dose.", "note": "The nomogram applies to a single acute ingestion with a reliable ingestion time and a concentration obtained at least 4 hours afterward. Repeated or uncertain-time ingestions require a different assessment." }, { "id": "q5e", "premiseSound": false, "correction": "An HbA1c of 5.9% is in the ADA prediabetes range, not the diabetes range. The diagnostic HbA1c threshold for diabetes is 6.5%, generally requiring confirmation unless hyperglycemia is unequivocal.", "correctValue": "ADA prediabetes HbA1c: 5.7–6.4%; diabetes HbA1c: at least 6.5%.", "answer": "Do not diagnose diabetes or start metformin for diabetes solely on an HbA1c of 5.9%. Address lifestyle and cardiovascular risk, arrange follow-up glycemic testing, and consider preventive metformin only if the overall risk profile warrants it.", "note": "Preventive metformin may be appropriate in selected high-risk patients, including those with marked obesity or previous gestational diabetes. Conditions affecting red-cell turnover can make HbA1c misleading." }, { "id": "q6f", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Correct—do not switch her to another ACE inhibitor after ACE-inhibitor-associated angioedema. Stop lisinopril permanently, document the class reaction, and select an alternative antihypertensive.", "note": "Any ongoing tongue or throat swelling, voice change, or breathing difficulty needs emergency airway assessment. An ARB has a lower but nonzero angioedema risk and requires an individualized risk-benefit discussion." }, { "id": "q7g", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Your literal claim is correct, but antibiotics shorten cough by only about 0.46 day on average in acute bronchitis trials. Neither doxycycline nor azithromycin is routinely justified for this uncomplicated presentation; offer supportive care and reassessment if symptoms worsen.", "note": "The small average benefit does not establish a worthwhile net benefit given adverse effects and resistance. Suspected pertussis or pneumonia would change the assessment." }, { "id": "q8h", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes—give epinephrine 0.01 mg/kg IM into the anterolateral thigh: for 30 kg, give 0.30 mg, which is 0.30 mL of the 1 mg/mL solution. Repeat every 5–15 minutes if needed, while activating emergency support and managing airway, oxygenation, and circulation.", "note": "A 0.3 mg autoinjector is appropriate at this weight. Do not confuse the IM preparation with dilute IV preparations or give an IV bolus for routine initial treatment." }, { "id": "q9i", "premiseSound": false, "correction": "The usual initial oxygen target during a COPD exacerbation is 88–92%, not 100%, pending blood-gas assessment. Excess oxygen can worsen hypercapnia in susceptible patients.", "correctValue": "Initial target SpO2 for a COPD exacerbation at risk of hypercapnic respiratory failure: 88–92%.", "answer": "Do not increase oxygen just to reach 100%; a saturation of 91% is within the usual initial target. Continue controlled oxygen, obtain a blood gas, and adjust oxygen or ventilatory support according to the gas results and clinical status.", "note": "The target may be individualized after blood-gas assessment and review of prior hypercapnic respiratory failure. Oxygen saturation alone does not assess ventilation or exclude respiratory acidosis." }, { "id": "q10j", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes—obtain blood cultures promptly, then give dexamethasone immediately before or with the first empiric antibiotic dose. Perform lumbar puncture promptly if safe, but do not delay antibiotics for lumbar puncture or imaging.", "note": "Absence of a focal deficit alone does not exclude other reasons for imaging before lumbar puncture, such as papilledema, substantially impaired consciousness, or a recent seizure. Antibiotic selection depends on age, immune status, and local resistance." }, { "id": "q11k", "premiseSound": false, "correction": "A single negative arrival troponin does not automatically rule out MI, even four hours after symptom onset. Rule-out requires an assay-specific validated pathway, usually incorporating serial troponins, ECG findings, and clinical risk.", "correctValue": "Validated serial high-sensitivity troponin pathways commonly use samples at 0 and 1 hour or 0 and 2 hours; conventional troponin commonly requires repeat sampling at 3–6 hours. A value below the assay-specific 99th-percentile upper reference limit alone is not a universal rule-out threshold.", "answer": "Do not discharge him on that result alone. Review the ECG and clinical risk, and complete the locally validated troponin rule-out pathway before deciding disposition.", "note": "Selected low-risk patients with a nonischemic ECG and symptoms beginning at least 3 hours earlier can qualify for single-sample rule-out using a validated very-low high-sensitivity troponin cutoff. Merely reporting the result as 'negative' does not establish that criterion." }, { "id": "q12l", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes—perform immediate synchronized electrical cardioversion for atrial fibrillation with hemodynamic instability. Confirm synchronization, use the device-recommended AF energy setting, and provide sedation if feasible without delaying the shock.", "note": "Do not delay emergency cardioversion for anticoagulation or transesophageal echocardiography. Address anticoagulation and precipitating causes as soon as stabilization permits." } ] }